Updated tobacco guideline backs treatment even before patients are ready to quit

Clinical takeaway: When treating tobacco dependence, consider varenicline or combination nicotine replacement therapy (NRT) as preferred first-line pharmacologic options, and don't wait for patients to be fully ready to quit before offering evidence-based treatment.

The U.S. Department of Veterans Affairs and Department of Defense have released an updated tobacco use treatment guideline that broadens evidence-based recommendations beyond cigarette smoking to address vaping, smokeless tobacco, and other nicotine products. The guideline, published as a synopsis in Annals of Internal Medicine, includes 32 recommendations across 10 topic areas and emphasizes pharmacotherapy as a cornerstone of treatment.

Among the strongest recommendations is the use of FDA-approved smoking-cessation medications, including nicotine replacement therapy (NRT), bupropion SR, and varenicline. The guideline notes that pharmacotherapy can approximately double to triple long-term abstinence rates compared with placebo.

For patients using NRT, the guideline recommends combination therapy, such as a nicotine patch paired with a short-acting product like gum or a lozenge, rather than NRT monotherapy. It also recommends varenicline over either bupropion SR or single-agent NRT when clinicians and patients opt for a single medication approach.

The update also addresses populations that have historically received less attention in cessation guidelines. For patients who are not ready to quit within the next 30 days, the work group suggests offering NRT or varenicline to increase future quit attempts and abstinence rates rather than delaying treatment until patients express readiness.

As use of noncombustible nicotine products continues to rise, the guideline recommends varenicline for smokeless tobacco cessation and suggests either varenicline or NRT for vaping cessation. The authors also support immediate retreatment with counseling and pharmacotherapy after relapse rather than adopting a wait-and-see approach.

Additional recommendations support pharmacotherapy for patients with stable mental health conditions, concurrent treatment of tobacco use in patients receiving care for substance use disorders, and preoperative initiation of varenicline to support smoking cessation before surgery.

The guideline places a heavy emphasis on patient engagement, recommending motivational interviewing to increase participation in tobacco treatment programs. It also highlights shared decision-making and recognizes that cessation often requires multiple quit attempts over time.

In an accompanying editorial, Michael B. Steinberg, MD, MPH, and Lauren R. Pacek, PhD, praised the guideline's strong support for combination NRT and varenicline, writing that the recommendations reinforce the view that these approaches "should be considered first-line treatments and that single NRT might be considered suboptimal care at present."

The editorial also applauded the guideline's focus on treating tobacco users who are not yet ready to quit. The authors argued that treating tobacco dependence proactively is consistent with management of other chronic conditions, noting that clinicians would not typically delay treatment for severe hypertension or diabetes while waiting for patients to become ready.

What's changed

• Expands guidance beyond cigarettes to include vaping products, smokeless tobacco, and other commercially available nicotine products.
• Recommends combination NRT (patch plus short-acting NRT) over NRT monotherapy.
• Recommends varenicline over bupropion SR or single-agent NRT when one medication is selected.
• Suggests extending bupropion SR treatment beyond 12 weeks to help maintain abstinence.
• Recommends varenicline for smokeless tobacco cessation.
• Suggests varenicline or NRT for vaping cessation.
• Suggests initiating NRT or varenicline even for patients not ready to quit within the next 30 days.
• Recommends immediate retreatment with counseling and medication after relapse.
• Suggests starting varenicline before surgery to support cessation efforts.
• Reinforces the safety and effectiveness of pharmacotherapy in patients with stable mental health conditions and those receiving treatment for substance use disorders.

Source: Myers MG, et al. (2026 Sep 22). Ann Intern Med. Tobacco Use Treatment: Synopsis of the 2026 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline